Abdominal Procedures Flashcards
Layers to get to the abdomen
- Skin
- SQ fat
- Camper’s Fascia
- Scarpa’s Fascia
- Abdominal Wall Fascia
- Pre-peritoneal Fat
- Peritoneum
Types of Incision used is dependent on?
Maximum exposure and location of patholog
What types of incisions are there?
- Midline (incision of indecision)
- Kocher incision
- Pfannelstiel
- Clam Shell
- Chevron
- McBurney Incision
- Paramedian
If the pt has had a prior sx, what is important to take into account when choosing an incision?
- Danger of adhesive dz
- Possible bowel injury
- Devascularizing skin (paramedian/midline)
Define Extensile Exposure
Basically, you can start with a smaller incision that can become another one.
Ex. Midline can continue to a midline sternotomy, or the Kocher and be extended to a clam shell.
This is a type of abdominal surgery that accesses the abdomen with small incisions and can insufflate the intraperitoneal cavity with CO2. They use a camera and specialized equipment for this.
Laparoscopy
What are the advantages of a laparoscopy sx?
- Minimal Access (Less scarring)
- Decreased Pain
- Shorter Hospitalization
- Better Anatomic Visualization
Disadvantages of a laparoscopy sx?
- Carries same risks as open sx plussss gas embolism and pneumothorax
- May require conversion to open sx
- Poor visualization
- No tactile sense
CI for Laparoscopy?
- Inability to withstand general anesthesia
- Hypovolemic Shock
- Heart Failure, Severe COPD cannot tolerate
- Pneumoperitoneum
- Intractable bleeding disorders
- End stage Liver Dz
Cholelithiasis Facts!
- Present in 12% of Americans
- 5 F’s
- Most are asymptomatic (doesn’t indicate sx)
- 70-80% of gall stones are cholesterol stones
Biliary Colic
- Symptomatic Gallstones
- Impaction of gallstone at the GB neck
- Intermittent RUQ pain-post prandially
- +/- NV
**Indication for elective cholecystectomy
Cholecystitis
- Gall stone obstructing cystic duct causing inflammation and wall distention
- Persistent RUQ pain, NV, Loss of Appetite
- Gallstone on US
- Murphy’s Sign
- Wall thickening
- Pericholecystic fluid with or without fever, WBC, elevated LFTs
**Indication for cholecystectomy
Choledocoholithiasis
- Obstructive Jaundice – GGT, Alk Phos, Total/Direct Bilirubin elevation
- Intermittent RUQ pain
- May resolve spontaneously, may require stone removal via ERCP or Sx
*** Patient should undergo elective cholecystectomy during the same hospitalization
5 F’s
- Fat (overweight)
- Forty (age near or above 40)
- Female
- Fertile (premenopausal- increased estrogen is thought to increase cholesterol levels in bile and decrease gallbladder contractions)
- Fair (gallstones more common in Caucasians)
Ascending Cholangitis
- Obstruction with bacterial stasis and inflammation
- Charcot’s Triad (Fever, Jaundice, RUQ Pain)
- Reynauld’s Pentad (Fever, Jaundice, RUQ Pain, Shock, Mental Status Change)
- MEDICAL/SURGICAL EMERGENCY
- Emergent fluids, foley catheter, abx, ICU admission
- Endoscopic decompression
*If that fails, then sx extraction of stone, t-tube drainage of biliary system
Biliary Pancreatitis
- Occurs primarily in acute obstruction
- Most often secondary to gallstones, but can be due to malignancy
- Epigastric pain radiating to back, vomiting, elevated amylase/lipase
- Initial medical management (NPO, IVF, NGT, Pain Control)
- Stone extraction - ERCP
- Cholecystectomy during same hospitalization once enzymes normalize
DDx for RLQ Pain
- Colitis
- Diverticulitis
- Inguinal Hernia
- UTI
- Pyelonephritis
- Ureteral Calculus
- PID
- Ectopic Preggo
- Mesenteric Adenitis
- APPENDICITIS
Acute Appendicitis
- NV, Anorexia
- Pain starting centrally, moving to RLQ
- Localizes at McBurney’s Point
- Fever, mildly increased WBCs
- CBC, UA, Pelvic/Rectal Exams
- CT often performed but rarely necessary
- Appendectomy – usually lap
Perforated Appendicitis
- Waxing/Waning course with sudden recovery
- Re-emergence of symptoms/fever
- CT scan for Dx, percutaneous drainage
- At 6 weeks (1/ interval) appendectomy is performed
Open Sx Appendectomy
- McBurney/Lanz/Rocky Davis Incision
- Identify the cecum
- Deliver the appendix into the wound
- Control mesoappendix, divide appendix control base - purse string suture
***Higher rate of local wound infection
Laparoscopic Appendectomy
- 3 ports (5 mm umbilicus, 5mm suprapubic, 10 mm LLQ)
- Identify appendix separate from cecum
- Lap Stapler to divis appendix and mesoappendix
***Higher rate of pelvic abscess
DDx for LLQ Pain
- Colitis
- Appendicitis
- Inguinal Hernia
- UTI
- Pyelonephriti
- Ureteral Calculus
- PID
- Ectopic Preggo
- DIVERTICULITIS
Wth is the diverticula? Really doe?
Outpouching of weakened colon at site of vascular perforation. Typically the left (sigmoid) colon.
Commonly seen in older adults, but becoming more common in the young. When obstruction occurs, bacterial overgrowth can happen.
So wth is diverticulitis then?
- Presents with abdominal pain, bright red blood per rectum, fever, elevated WBC
- May form contained abscess amenable to CT drainage which may or may not be followed by operation
- May require urgent operation (sigmoid colectomy-Hartmann’s procedure)
Crohn’s Dz (Inflamm Bowel Dz)
- May affect mouth to anus, but usually spares rectum
- Presents with diarrhea, usually not bloody
- Transmural inflamm dz with cobblestoning and ulcers
- Dx with colonoscopy
- Inc risk of cancer
- Management is Medical (Anti inflamma, steroids)
- Surgical management only for bowel obstruction unresponsive to med management or if perforated
Ulcerative Colitis (Inflamm Bowel Dz)
- Colonic Inflammation, involves rectum
- Presents with diarrhea and red blood per rectum
- Friable mucosal dz with pseudo polyps
- Dx by colonoscopy with bx
- Inc risk of cancer
- Management is Surgical (total proctocolectomy with end ileostomy of ileal J-pouch)
When are ileostomies/colostomies used?
In situations where anastomosis between segments of bowel is no feasible or is unsafe, such as
- Contamination (trauma/perforation)
- Concern regarding blood supply
- Grossly dilated bowel (toxic megacolon, bowel obstruction)
- When further operations on a segment of bowel are planned (imperforate anus)
Post-op concerns of ileostomy or colostomy placement
- Ileostomy – Fluid loss, inability to absorb B12, Vit ADEK
- Colostomy – Loss of capacity to reabsory
-Both: Skin irritation, prolapse, parastomal hernia
Closing the Abdomen
- Count! Lap pads, instruments, malleable
- Visual inspection
- Tactile 4 quad search
- Ensure good paralysis
- Inform anesthetic team
- ICU/Resp Therapy/Transport
What sutures do you use for a Facial Closure?
- Running Suture
2. Interrupted suture
What do you do for a Skin Closure?
- None
- Stapled
- Suture (Interrupted, Running, Subcuticular)
What are retention sutures, and can they be used internally, externally, or both?
Retention sutures - help!
Can be used in both situations
What are other options in closing the abdomen?
- Secure Drains
- Ostomy Appliance
- Abdominal Binder
